Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Local Wound Care - Assessment
Recommendation Level of Evidence
3.1a  To plan treatment and evaluate its effectiveness, assess the pressure ulcer(s) initially for:
  • Stage/Depth;
  • Location;
  • Surface Area (length x width) (mm2, cm2);
  • Odour;
  • Sinus tracts/Undermining/Tunneling;
  • Exudate;
  • Appearance of the wound bed; and
  • Condition of the surrounding skin (periwound) and wound edges.
IV
3.1b  Conduct a comprehensive reassessment weekly to determine wound progress and the effectiveness of the treatment plan. Monitor for variances from assessment with each dressing change. Identification of variances indicates need for reassessment. IV

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